Home Health & Hospice Week

If additional development requests for claims under medical review get lost in the shuffle at your home health agency, you're letting reimbursement needlessly slip through your fingers. Failing to send in medical records by the 30-day deadline (denial code 56900) was the number-one reason HHAs saw claims denials from regional home health intermediary Palmetto GBA last October, according to a list of the top 10 denial reasons recently posted to Palmetto's Web site. Although responding to ADRs on time might seem like a basic activity, there are a number of reasons agencies have trouble complying. HHAs that rely on receiving paper ADRs might not even be aware they have claims under medical review if they're failing to check for the requests online, says consultant Kay Hollers with Austin, TX-based Healthcare Executive Resources. Or ADRs might be directed to the wrong person at an agency, points out consultant Laura Gramenelles with Simione Consultants in Hamden, CT. By the time requests make it to the right person, agencies could be pushing the 30-day time limit. The problem could be with HHAs getting responses out the door on time. If ADRs migrate to the bottom of a staffer's workpile while she attends to other issues, the deadline can sneak by. Or if the response has to pass through a battery of eyes before submission, one slow link in the review chain can cause a fatal delay, notes Gramenelles. Failing to respond to an ADR properly "is the worst reason to lose money," insists Hollers. And it's largely preventable. HHAs must make ADR processing a priority, Hollers stresses. That includes implementing a fool-proof tracking system for requests that begins with daily online checking for ADRs, Gramenelles advises. If the claim is in status SB6001 on the Direct Data Entry (DDE) system, you must send in supporting records, Palmetto directs. Agencies that feel they send the responses on time but don't get credit for them should use a mail delivery method that requires proof of receipt from the intermediary, Hollers recommends. Providers should return the medical records to the address on the ADR, Palmetto instructs. And providers should keep copies of everything they send in, so they can re-send materials quickly if they become lost, Hollers adds. Another top denial reason found by Palmetto was upcoding (denial code 5DOWN). In those cases, "the home health agency has billed services at a higher payment level than the medical documentation submitted supports, as a result reimbursement has been adjusted to a lower payment level," Palmetto explains. In OASIS v. Chart, HHAs Lose The main culprit here is a discrepancy between the OASIS assessment and the chart documentation, Gramenelles says. Medical reviewers pore over both documents to assure [...]